Republicans Grapple With How to Repeal 'Obamacare'

Republicans on Capitol Hill have begun both tamping down expectations and trying to allay fears about how fast they can and should dismantle key components of President Obama's signature health care law.

House Speaker Paul Ryan in a television interview last week said that while Congress plans to vote to overturn and defund parts of the Affordable Care Act as soon as possible, "it's going to be years" before people who have access to insurance because of the law have to transition to a new program.

Republicans have campaigned for the last six years on a pledge to repeal the law immediately and, since the presidential election, GOP lawmakers have doubled down on that promise. But details remain up in the air.

Most likely, Republican lawmakers will in January vote on a special budget package to cut funding for programs in the law down the road. That is the "repeal" part. They would not need Democratic cooperation on this because certain budget bills can be passed with a simple 51-majority vote in the Senate under a process called reconciliation. But those bills must be limited in scope and cannot overturn regulatory rules or marketplace standards such as the law's ban on lifetime coverage limits.

"People don't understand that a 'repeal' doesn't mean that you pull the rug out," Ryan said during the interview on CNBC. He added that he did not want Americans "going back to the emergency rooms," because they lost their health care. So, to protect the estimated 20 million Americans who gained health insurance from being left high and dry, it is likely that Republicans will write the budget bill so that funding cuts don't take effect for a year or two.

"I think now the line is more like 'repeal and delay,' Dr. Michael Chernew, director of the healthcare markets and regulation lab at Harvard Medical School told ABC News. "It is symbolically important for them to repeal the Affordable Care Act, but deleterious in terms of policy to stop it right now before they know what they want to do."

Chernew said he expects that most public subsidies that allowed for states to expand coverage through Medicaid and establish marketplaces for consumers to buy individual insurance will remain through 2017 and perhaps even 2018 in order to maintain relative stability in the health care industry and the overall economy. Under this scenario, people would still be able to buy individual insurance through state-based marketplaces for another year or so. But again, Republicans say all details have yet to be ironed out.

Senate Majority Whip John Cornyn told reporters this week that replacing "Obamacare" may be a long-term project. "It took six years to get where we are now and demonstrate the failure of 'Obamacare,' so it's going to take us a little while to fix it," he said.

More Questions Than Answers

The Affordable Care Act was drafted by Democrats with the aim of getting insurance companies on board with the law's new requirements and expanded coverage by also imposing mandates that consumers who can afford to buy insurance do so. The law also introduced public subsidies to make it easier for people to buy insurance if their employers do not offer it. Approximately 20 million previously uninsured Americans have gained coverage since the law went into effect, according to the Obama administration.

Republicans on Capitol Hill have repeatedly said they want to maintain popular provisions of the law, such as prohibiting insurers from denying coverage for pre-existing conditions and requiring them to allow young adults up to age 26 to stay on their parents' plans. However, as Democrats have been quick to note, Republicans have yet to offer specifics on how they would get insurance companies to fulfill these requirements without also continuing the mandate for consumers to buy insurance. The mandate is supposed to ensure that more people, especially the young and healthy, buy coverage, which can help keep overall premium costs down.

Experts, including two major national hospital advocacy organizations as well as the American Actuary Group, wrote to Republicans recently warning that cutting funding for some parts of the law immediately without at least a blueprint for a future plan could send shockwaves through the health insurance industry and lead to the collapse individual insurance markets. In short, millions of Americans could lose insurance, and doctors and other health care providers could lose paying customers.

"The [Affordable Care Act] was designed to solve a problem," Chernew said of the millions of Americans who were previously uninsured and now have coverage. "You can debate whether or not it was a good way to solve that problem or whether it was successful -- and there were some successes and some not -- but the underlying problem remains" of keeping people insured.

House Majority Leader Kevin McCarthy wrote to governors across the country seeking their input and advice and told reporters that Republican lawmakers were thinking and talking about these challenges. "We're seeing how we can solve the problem but nothing to report yet," he said. "Wait to see what we draft."

Democrats, however, have pounced on the lack of details. "They said they want to start repealing 'Obamacare' the first week ... Bring it on," incoming Senate Minority Leader Chuck Schumer said. "They don't know what to do. They know they can't just repeal it. They have nothing to put it in its place."

"Just repealing 'Obamacare' will cause huge calamity," he said. "They are like the dog that caught the bus."